Rapid Acquisition Of Key Concepts General Medicine

Apr 17, 2024

Brainstem Reflexes

Test	Afferent	Efferent	Procedure
Pupillary reflex	II	III	A bright light is shone into each eye in turn to look for direct and consensual reflexes
Corneal reflex	V	VII	The cornea is brushed lightly with a swab
Response to painful stimulus	V	VII	A painful stimulus is applied to the supraorbital ridge
Vestibulo-ocular reflex	VIII	III, IV, VI	Visualise the tympanic membrane prior to beginning the test. Instil 50 ml ice cold saline into each external auditory meatus in turn, looking for eye movement/ nystagmus
Gag reflex	IX	X	The pharynx is stimulated with a spatula/ similar device
Cough reflex	X	X	A bronchial catheter is passed down the endotracheal tube to stimulate the carina

Mallampati Grading

Class I	Visualize the Entire soft palate Uvula Fossces Anterior and posterior pillars
Class II	Visualize the Entire soft palate Uvula (Partially) Fossces (Partially) Anterior and posterior pillars are not visible
Class III	Visualize the Entire soft palate Uvula (Base) Fossces, anterior and posterior pillars are not visible
Class IV	Soft palate is invisible

Paralysis With Induction Drugs

Etomidate	Dose: 0.3 mg/kg Onset of action: 10-15 sec Duration: 4-10 mins DOC for rapid sequence intubation In case of cardiogenic shock Hemo neutral (No alterations in BP and HR) Side Effect: Decreases the glucocorticoid synthesis Ketamine: Used in sepsis or septic shock
Ketamine	Class: Phencyclidine Dissociative anaesthetic Standard dose: 1-2 mg/kg Onset of action: 45-60 secs Duration of action: 10-20 mins Preferred in case of agitation Has hemodynamic consequences Increases the BP, HR Increased mean arterial pressure Preferred in case of shock Exception: Cardiogenic shock Raised ICP Causes bronchodilation Avoid ketamine in case of normal or raised BP Contraindication: Patients with raised ICP Avoid in cardiovascular diseases
Midazolam	Class: Benzodiazepines Dose: 0.1-0.3 mg/kg Has highly variable response Not routinely preferred Onset of action: 45-90 secs Duration: 15-30 mins Produce amnestic effect Side effects: Dose dependent Myocardial depression Respiratory depression
Propofol	Class: Alkyl phenol Dose: 1-3 mg/kg Milky white in colour Onset of action: 15-45 secs Duration: 5-10 mins Causes dose dependent hypotension Uses Bronchodilation: RAD Status epilepticus Secondary or third choice of drug Causes propofol infusion syndrome Due to its prolonged use
Thiopentone	Class: Ultra short acting barbiturate Other Name: Tooth serum Onset of action: <30 secs Duration: 5-10 mins Side effects Dose dependent hypotension Bronchoconstriction Histamine release Not used in RAD Powerful venodilators or myocardial suppression Precipitate acute attack of porphyria Uses Cerebroprotective Anticonvulsants

Post Intubation Hypoxemia

Endotracheal tube malposition: Reasons
Tube is in the oesophagus	Diagnosis: Capnography Treatment: Reintubation
Main stem intubation or right endobronchial intubation	Diagnosis: Clinical Chest X ray: Confirmation test Treatment: Adjust and pull the tube (Slightly)
Cuff leak	Diagnosis: Loss of pressure in pilot balloon
Mucus plugging	High peak inspiratory pressure High resistance to BVM Treatment: Bronchoscopy or suction
Rapid desaturation	Inadequate preoxygenation Decreased time for desaturation Normal time: 8-10 mins Patients with morbid obesity Restrictive lung disease 3rd trimester of pregnancy Shunt formation because FRC is very low Fast intubation is recommended

Rapid Sequence Intubation

Preparation	Standard
Preoxygenation	3 mins or 8 vital capacity breaths
Pre-medications	-
Induction paralysis	Etomidate:20 mg/IV Succinylcholine 100 mg/IV
Positioning	Standard sniffing
Placement	Direct laryngoscopy Proof (Waveform capnography: ETCo2)
Post RSI management	Regular
Miscellaneous	-

Rapid Sequence Intubation (RSI) In Raised ICP

Preparation	Standard
Preoxygenation	3 mins or 8 vital capacity breaths
Premedications	Lignocaine 100 mg/IV ± Fentanyl 200 mcg/IV
Induction paralysis	Etomidate:20 mg/IV Succinylcholine 100 mg/IV Ketamine is contraindicated
Positioning	Standard
Placement	Direct laryngoscopy Proof (Waveform capnography: ETCo2)
Post RSI management	Therapeutic hyperventilation PaCo2: 30-35 mmHg <30: Severe hypoperfusion
Miscellaneous	Raised ICP care

Rapid Sequence Intubation (RSI) In Reactive Airway Disease

Preparation	Standard
Preoxygenation	3 mins or 8 vital capacity breaths
Premedications	Lignocaine 100 mg/IV
Induction paralysis	Ketamine 100mg/IV Succinylcholine 100 mg/IV
Positioning	Standard
Placement	Direct laryngoscopy Proof (Waveform capnography: ETCo2)
Post RSI management	Bronchodilators High peak inspiratory pressure: Bronchoconstriction
Miscellaneous	-

Rapid Sequence Intubation (rsi) In Pediatrics < 10 Years Of Age

Preparation	Standard
Preoxygenation	3 mins or 8 vital capacity breaths
Premedications	Atropine 0.02 mg/kg/IV
Induction paralysis	Etomidate 0.3 mg/kg/IV + Succinylcholine 1.5 mg/kg/IV
Positioning	No need of sniffing
Placement	Standard + Proof (Waveform capnography: ETCo2)
Post RSI management	Standard
Miscellaneous	-

Points Regarding ACLS Algorithm

CPR Quality	Rate of chest compressions should be 100-120/min Depth: 2 inches or 5cms Minimize interruptions in compressions Avoid excessive ventilation Change the compressor every 2 minutes, or Sooner if fatigued No advanced airway: 30:2 (Compression-Ventilation ratio) Quantitative waveform capnography PETCO is low or decreasing Reassess CPR quality
Shock energy for defibrillation	Biphasic Manufacturer recommendation (e.g., initial dose of 120-200 J) Unknown, use maximum available Second and subsequent doses should be equivalent, and Higher doses may be considered Monophasic: 360 J
Drug therapy	Epinephrine IV/IO dose 1 mg every 3-5 minutes Amiodarone IV/IO dose First dose: 300 mg bolus Lidocaine IV/IO dose First dose: 1-1.5mg/kg Second dose: 0.5-0.75 mg/kg
Advanced airway	Intubate the patient and connect to the ventilator

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